32 Physical Examination Hemodynamic Stability Signs of acute CHF Sternal woundPVDStrokePM/ICDEvidence of AV dissociation (cannon A waves, marked fluctuations in BP, variable S1 intensity)Maneuvers: CSM, pharmacologic interventions (lidocaine, adenosine, BB, verapamil)
33 Other testsLaboratory tests: K, Mg, plasma concentrations of drugs (dig, procan, etc…)CXR: cardiomegalyEcho: structural abnormalities
34 ECG In NSR: AV dissociation Ischemia Fusion beats Acute MI During WCT:AV dissociationFusion beatsCapture beatsMorphologyWidth of QRSMorphology of the bundlesElectrical axisPrecordial concordanceIn NSR:IschemiaAcute MIOld MILong QTBrugada patternLVHEpsilon waves
39 Therapy Acute Management: For the Unstable patient: Emergent synchronized cardioversionIf QRS and T cannot be distinguished then defibrillationCautious use of sedatives and analgesicsFor the Stable patient:Class I or III AADTreatment of associated conditions (ischemia, electrolytes,…)Elective cardioversionInterrogation of ICD or PM if present
40 Therapy Chronic Management: AAD: EPS+/-RFA ICD class IC or III, if structurally normal heartsclass III, if structurally abnormal hearts (with ICD)EPS+/-RFAStand alone therapy in idiopathic VTAdjunctive therapy (+/-AAD) in ischemic VTICDFor primary and secondary prevention of SCD
45 Special Case: NSVT EF≤35%, then ICD EF>40%, no ICD 35%<EF≤40%, then EPS and ICD if EPS+ (MUSTT trial)In all these cases, -blockers and other AAD can be used if NSVT is symptomatic.
46 SummaryDDX of WCT includes VT, SVT with aberrancy, preexcited tachycardia, artifact, and paced rhythm. VT accounts for 80%Diagnosis hinges of good history, PE, ECGAcute management depends on stability of patient. In the unstable patient, immediate cardioversion or defibrillation is recommendedLong term management armamentarium includes: AAD, Ablation, ICD